Will I hurt the baby?

They were the first words that entered Kathryn Nobrega’s mind after giving birth in February 2004. She had dreamed of being a mother her entire life; now, at 40, she finally was. But the moment she awoke from anesthesia—she had a cesarean section after a painful four-day labor—those three ugly words broke into her brain and refused to leave.

Her pregnancy had been seamless, her mood ecstatic. “I wanted this baby so badly,” recalls Nobrega, a management consultant in San Francisco. A semiprofessional musician, she continued to perform in an R&B band through her seventh month. “Emotionally I was in the best place I’d ever been,” she says. “I remember being onstage and looking out into the audience, feeling in love with everything around me because I was bringing a child into the world.”

But as her delivery date neared, peculiar, frightening and violent thoughts began to invade her calm. “I was going through the ritual of washing all the baby clothes I’d gotten as gifts, and as I was taking them out of the dryer, I was struck by how small they were, how small and vulnerable he would be and how easy it would be to hurt him,” she says. “Looking at the empty crib that was waiting for his arrival terrified me, because I’d imagine it covered in blood.”

Nobrega soothed herself with the belief that once her son, Miller, was born—once she could hold him and know he was OK—her unsettling thoughts would vanish. But they only became more graphic. “I could suppress them fairly well while I was pregnant, but after he arrived my mind was like a runaway train,” she says. When she and her husband, Jim, brought Miller home from the hospital to their one-bedroom apartment in Haight-Ashbury, the baby was swaddled in a light-blue blanket, his little arms tucked tightly inside, his face peeping out of the soft cotton. Nobrega looked at his tiny body asleep on the beige, oversize couch in her living room. Rather than revel in his sheer adorableness, she thought to herself: “What if someone shot him? He’d pop like a water balloon.”

In her heart, Nobrega knew she would never harm Miller. Still, she couldn’t even be in the kitchen with her newborn son without imagining him bleeding to death from knife or scissor wounds. The terrible images repeated themselves over and over, again and again, like a never-ending film loop conspiring to drive her to the edge of sanity. “To this day even my husband doesn’t know all the details of what ran through my mind,” Nobrega confesses. “I felt like a monster.”

First-time moms like Nobrega are often hypervigilant about their child’s safety, feeling anxious about everything from germs to freak accidents and sudden infant death syndrome. And doctors say those fears are perfectly normal, part of the hormonal hard wiring known as the maternal instinct. Our worries help keep us vigilant, and when we take action to protect our children, they usually pass. But in some new mothers, these protective instincts go into overdrive and turn into something more: postpartum obsessive-compulsive disorder, or PPOCD. Research now suggests that pregnancy and the postpartum period are the life events most likely to trigger OCD in women, and symptoms can appear just after delivering a baby. Yet PPOCD is underresearched, misunderstood and frequently misdiagnosed or not diagnosed at all.

Widespread confusion about the disorder within the medical and mental-health community often exacerbates women’s sense of helplessness, says Karen Kleiman, director of the Postpartum Stress Center, a treatment facility in Rosemont, Pennsylvania. And the fear of having their children taken away hushes many of them into silent suffering. “This problem is more prevalent than anyone can imagine, and yet the women who have it are so ashamed of these thoughts that they don’t tell a soul,” Kleiman says. “Imagine worries that start off revolving around the bathwater being too hot and then catapult into images of ripping off your own baby’s limbs. The shame and the fear are incomprehensibly huge.”

Most new moms—between 70 and 85 percent of them—get the “baby blues” in the days following childbirth, according to the National Mental Health Association in Alexandria, Virginia. Feeling moody and weepy is a normal response to the hormonal turmoil that occurs after pregnancy, not to mention the exhaustion of caring for a newborn. When this sadness is more severe and lasts two or more weeks, doctors diagnose postpartum depression, an illness affecting between 10 percent and 12 percent of new mothers. Close to 30 percent of those women will exhibit some degree of obsessional symptoms, according to Shaila Misri, M.D., clinical professor of psychiatry and obstetrics and gynecology at the University of British Columbia in Vancouver. PPOCD can also exist by itself and even bring about the onset of depression.

Some women with postpartum OCD are plagued only with compulsions—they find themselves washing their hands raw, housecleaning constantly or waking up every 15 minutes throughout the night to make sure the baby is still breathing. In most instances, these women are able to function and enjoy motherhood. But in more than half of cases, according to Dr. Misri, women also suffer obsessional thoughts without compulsions, uncontrollable and often violent visions of harm coming to their newborn, sometimes at their own hand: thoughts of dropping a child down the stairs or out the window, putting him in the microwave or throwing him into a fireplace. They may feed these obsessions by actively seeking out morbid news stories and violent programs on television or the Internet and then endlessly imagining the same awful things happening to their family. Though they know they would never follow through on these impulses, they still cannot keep the ideas at bay. “The person with OCD suffers deeply because she knows she is disabled,” Dr. Misri says. “And yet she can’t imagine what she can do to help herself.” The fears are too flat-out scary to be uttered aloud.

The disorder’s cause remains hazy, says Ruta Nonacs, M.D., associate director of the Perinatal and Reproductive Psychiatry Clinical Research Program at Massachusetts General Hospital in Boston. In general, OCD is an anxiety disorder associated with an abnormal production of serotonin, one of the brain hormones that affect mood. Doctors suspect that the influx of estrogen, progesterone and other hormones during pregnancy, followed by the dramatic depletion of those hormones immediately after delivery, may somehow cause serotonin production to go awry. Hormones aside, stressful situations are known to kick-start OCD. And that risk is particularly true, Dr. Nonacs suggests, for “any situation where a lot is expected of you, such as first-time motherhood, for which few people are truly prepared.”

At least half of women who have postpartum obsessive-compulsive disorder did not have OCD before giving birth, says Valerie Raskin, M.D., assistant clinical professor of psychiatry at the University of Chicago Medical School. Even so, experts assert it’s likely that sufferers may have at one time been diagnosed with depression or symptoms related to OCD, have a family history or had minor symptoms of it all along but somehow failed to notice. “Maybe before childbirth you were someone who checked the stove three times before you left the house or hung your towels in a certain way,” Dr. Raskin says. “These behaviors may not have adversely affected your life, but they might have been red flags for what was in store. Pregnancy and postpartum can push a type A compulsive personality over the edge into OCD. I’ve seen it happen to very high-functioning women: accountants, lawyers, engineers, people who by their very nature are extremely precise. Perfectionists who need everything in a certain order are the most likely to fall off this emotional cliff. They begin to imagine that everything, including themselves, is a threat to their baby.”

That’s exactly what happened to Wendy Isnardi of Suffolk County, New York. Isnardi, a 33-year-old stay-at-home mom who worked previously as a human resources advisor, was by nature a worrier. “If I had a headache it meant I had a brain tumor,” she says. “If I heard about a car accident on the radio I was certain it involved someone I loved.” Her friends joked about her habit of calling them in the middle of the day just to make sure they were still alive. “People knew something was wrong with me,” she says, “but it was like funny wrong, not serious wrong.”

After Isnardi gave birth to her daughter, Madison, in July 2002, her neuroses were no longer so laughable. “When my friends came over, I ran around spraying everything with Lysol,” she says. “One time when a friend’s son coughed I couldn’t wait for them to leave, then I scrubbed the door handles and anywhere this kid might have even thought to touch.” She grew panicky when anyone else—including her own mother—held the baby. “I felt no one knew as much about caring for a baby as I did, even though Madison was my first,” she says.

Three weeks after Madison’s birth, Isnardi and her mother sat down to watch The Others, the horror film in which a character is revealed to have killed her children. Isnardi had seen the film before and wasn’t bothered by it. But that night, peering into Madison’s angelic face as she slept in her bassinet next to the sofa, “I suddenly realized how easily I could harm my daughter,” she says. When she picked Madison up to hold her to her chest, the baby’s neck snapped back in the quick, jerky way newborns’ heads sometimes do. “It would have been so easy to break her neck, I realized, or to step on her. That night was the beginning of the end for me.”

Now everything Isnardi did posed a danger to Madison, at least in her mind. Driving on the Long Island Expressway, she peeked in the rearview mirror, convinced her child would fly out of the window and into traffic, even though Madison was buckled into her car seat and the window was closed. Places once safe and familiar became triggers for terror, a hallmark symptom of PPOCD. While shopping at a local mall, Isnardi glanced down to the food court three stories below. “I had this image that I could push Madison over the balcony,” she recalls. “The thought made me so sick that I threw up.”

The real danger of postpartum OCD is not that a woman will act on gruesome obsessions like these. Rather, it’s that she can become so fearful of losing control that she may end up neglecting her baby, says Shari Lusskin, M.D., clinical assistant professor of psychiatry and ob/gyn at New York University School of Medicine in New York City. She recalls one patient, for example, who was so concerned about harming her child that she didn’t change his diaper for three days, resulting in a severe rash. “The impact of this condition cannot be underestimated,” Dr. Misri adds. “Women can be so distracted by these thoughts that they are too distressed to properly take care of themselves or their newborn children.”

In the Chicago apartment of Candice Maurer, the living room sofa is big and overstuffed, its pillows so fluffy, she’s probably tempted to doze off the instant her head touches down on them. But sleep was one of the many things that Maurer, a 23-year-old student at Northeastern Illinois University, tried desperately to avoid during the first six months of her daughter Lily’s life. Whenever she sat on the couch, she threw its pillows to the floor. “I didn’t want to fall asleep, because if I did, I might sleepwalk and then do something to hurt Lily,” she says. Maurer knew her fears made no sense: She had never sleepwalked in her life. But nothing could calm her thoughts. She loved Lily but felt incapable of caring for her.

Maurer had always been a neatnik and a perfectionist. She arranged the books in her bookcase not by topic or author, but by height—”from tall to short, the only way I can stand it,” she says. She separated her closets into sections of casual, work and dressy; subcategorized those into pants, skirts and shirts; and sorted each of those sections by color. In her second trimester of pregnancy, Maurer’s perfectionism intensified: She bought every baby book she could find and read at least five parenting magazines each month, rushing to the newsstand the morning each was released and then reading and rereading the articles and stacking them so high “sometimes I tripped on them when I got out of bed,” she says. She now believes that her fixation on baby books and magazines marked the onset of her obsessive thoughts about her daughter.

After Lily’s birth, Maurer became so worried she would harm her daughter that she sought excuses to avoid her. Whenever her fiancé, Patrick, was home, “I’d run to the kitchen to do the dishes, even if there were only two plates in the sink,” she says. “Or I’d spend hours doing laundry, just so I wouldn’t have to be in the same room with her.” The big green couch became her safe spot. She would sit on it all day watching reruns of Friends or Will & Grace while Lily slept in a bassinet on the floor. “I knew if I just stayed there and watched TV, it would be OK,” she says. Maurer preferred her living room because it was sparsely furnished, with only two sofas, a TV set and a coffee table; there were no knives, pens, scissors or anything else that could be used as a weapon. She kept away from the second sofa because it was next to a two-story window, which in her mind made it too easy to throw Lily outside.

Maurer was equally frightened for her own safety. “Every day I woke up and thought, This is it,” she says. “I’m going to die on the floor of an aneurysm or a stroke, and Lily isn’t going to be taken care of.” Left alone with Lily one afternoon, she became so anxious that she went to the emergency room convinced she was having a heart attack. She refused to get behind the wheel of a car for fear of crashing, and she never took Lily outside for a walk in a stroller for fear of being hit by a car. Summer passed, then fall, and still she sat immobile on the couch.

Maurer knew something was wrong but had no idea what to do about it. She confided in her fiancé, but he assumed her fears were the same as any new mom’s. She began to keep a journal, to document her symptoms should she ever seek help for them. But the existence of a diary with detailed descriptions of her fantasies threw her into a panic. Fearing that someone might read it and take Lily away, Maurer tossed it in the garbage. “I grew really fixated on the idea that I might be one of those mothers who drown their children in the bathtub,” she says. “I couldn’t get those visions out of my head.”

One of “those mothers” is, of course, Andrea Yates, the Texas woman infamous for drowning her five children in bathwater, one by one. Yates was diagnosed with postpartum psychosis, a far more dangerous and far less common condition than PPOCD, affecting only about one in 1,000 new mothers. Regardless, her notorious case—last year an appeals court threw out her murder conviction, and at press time a retrial was scheduled to begin March 20—has instilled fear in medical professionals and new mothers alike. Now anyone who has visions of harming her child is a suspected murderer, even to herself. The confusion has made it all the more difficult for women with PPOCD to get the help they need.

The distinction between the two conditions should be clear. Women with postpartum OCD are appalled by their intrusive, violent thoughts. Women with postpartum psychosis see nothing wrong with theirs. “The first clue that a woman with PPOCD isn’t going to hurt her child is the very fact that she’s concerned about hurting her child,” says Dr. Raskin, who teamed with Kleiman to write This Isn’t What I Expected: Overcoming Postpartum Depression (Bantam). “Women who are truly psychotic and are a threat to their kids are the ones who don’t think that anything is wrong with them.” According to one study, 4 percent of women with postpartum psychosis actually kill their children; no one with postpartum OCD has been known to. Women with psychosis are also more likely than women with OCD to hear voices in addition to visualizing disturbing images.

Unfortunately, Dr. Nonacs says, many doctors can’t tell the difference. “Women often turn to their ob/gyn for this,” she notes. “The problem is that most physicians who aren’t trained in psychiatry don’t know how to distinguish PPOCD from a much more serious condition.” In several instances, children’s-protection authorities have been called to investigate mothers with postpartum OCD, and in at least one reported case, a newborn was taken from her mother for two weeks. “Women experience unnecessary trauma if they are not diagnosed or treated correctly,” says Shoshana Bennett, Ph.D., Kathryn Nobrega’s therapist and president of Postpartum Support International, an organization in Santa Barbara, California, for women living through various postpartum disorders. “I’d love to say that all professionals know the signs, but they don’t,” Bennett says. “Women with PPOCD are probably the least likely people on the planet to hurt their children.”

A month after Nobrega gave birth to Miller, she drove to a nearby medical center to meet with her internist about her obsessive thoughts. It was the second time she had left the house since she gave birth. But Nobrega’s regular internist was on vacation, and she ended up meeting with a doctor she had never seen before. When she described her symptoms, the doctor wouldn’t let her leave the office. Instead, she personally escorted Nobrega to the emergency room for a psychiatric consultation. “It was like Code Red,” Nobrega recalls. “I was terrified.”

Nobrega says the four or five hours she spent there were the most harrowing of her life. “I was scared that they’d make me stay in the hospital, or that they would let me leave but take Miller away,” she says. In all, it took five people—the internist, a psychiatric resident, a social worker, her trainee and finally the on-call psychiatrist—to determine that, as Nobrega puts it, “I wasn’t going to kill my baby.” She left the hospital with a prescription for Zoloft in hand but more terrified than ever: “After all of that, I worried whether I was capable of caring for my son.”

Obsessive-compulsive disorder rarely goes away completely without continued treatment, usually involving a combination of antidepressants and cognitive-behavioral therapy, which teaches patients to talk themselves down from an anxiety attack or obsessive thoughts. But this combination poses more challenges. Most cognitive-behavioral therapists are not medical doctors and have no authority to prescribe medications; Nobrega was forced to see one professional for therapy and another for medication. And while several studies indicate that there are antidepressant brands that are not harmful to pregnant women or breast-feeding babies, some doctors remain resistant to prescribing them. When they do, a provider may have not mastered the tricky dosing requirements of these potent drugs. And although the standard therapeutic dose of Zoloft for OCD is between 100 and 200 milligrams, for example, patients need to start on a far smaller dose of about 25 mg; too much too early can actually exacerbate a fragile mood disorder. That’s what happened to Nobrega, who consulted with three different psychiatrists over the course of six months to get the correct dosage of medication, one that would finally help ease her intrusive thoughts. “My deepest pain came from feeling that I was never going to enjoy this stage of my life that I’d always been waiting for, and that I would rob my baby of the joys of his childhood,” she says. “Because no one could really help me, I was convinced I would never get better.” Today both Nobrega and Maurer are able to be loving moms thanks to treatment, though both also suffer lingering anxiety disorders. Maurer has switched her major from design to psychology, in hopes of helping other women with PPOCD as a counselor or social worker.

Isnardi also struggled to find the right therapist, until her Lamaze coach introduced her to Sonia Murdock, executive director of the Postpartum Resource Center of New York. She spoke to Murdock on the phone every day for several months before joining a support group of other women struggling with postpartum disorders. “They made me feel normal, like I wasn’t alone,” she says. “They told me I was going to get better, and through their example I knew that I would.” Nearly four years after the birth of her daughter, Isnardi continues to take Zoloft and feels good enough that she is trying to get pregnant again, although she knows that women who have had PPOCD once are likely to have it again. “I have to hope that I’m better prepared for it this time,” she says, “and that taking drugs during my pregnancy will prevent that from happening.”

Several days a week, Isnardi volunteers her time fielding phone calls for the Postpartum Resource Center, the very place that helped her when she was in trouble. “I said that if I ever got better, which I couldn’t imagine, I would do anything I could to help other women who found themselves in this predicament,” she says. “There are some weeks when I speak to as many as 10 women from all around the country who sound exactly like I did, and each one of them is terrified that she is exactly like Andrea Yates,” she says. “Part of what they need to know is that they are not alone and they are not crazy. The other thing they need to know is that they will be OK.”